Analysis of cytopenia in geriatric inpatients.

BACKGROUND: Peripheral blood dyscrasias in older patients are repeatedly seen in geriatric clinical practice; however, there is substantial lack of data about the epidemiology, possible causes and treatment options in this patient group. Proton pump inhibitors (PPI) are extensively used in older patients and associated with leukopenia. The primary objective of this study was the assessment of encoded cytopenia prevalence in a geriatric patient cohort and the secondary objective was the assessment of putative causes and the analysis of PPI administration in patients with cytopenia. METHODS: Retrospective evaluation of patients admitted to the geriatric department of a German urban hospital between 2010 and 2012. Electronic patient data were screened for encoded diagnosis of cytopenia according to the International Classification of Diseases (ICD) 10. Inclusion criteria were ICD code D69.0-9 and/or D70.0-7, age ≥60 years and exclusion criteria were no ICD code D69.0-9 and/or D70.0-7 and age <60 years. Out of 9328 screened inpatients 54 patients remained for analysis. Study parameters included hemoglobin (Hb), red blood cell count (RBC), leucocytes, platelets, mean cell volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), presence of leukopenia (<4000/µl), presence of thrombocytopenia (<140,000/µl) and presence of anemia according to the World Health Organization (WHO). Substitution of blood products, medication with PPI and potential causes for dyscrasias were evaluated based on electronic patient records. RESULTS: The mean age was 78.3 ± 6.5 years (27 females, 27 males), anemia was seen in 78%, leukopenia was encoded in13% and thrombocytopenia in 44.4%. In most of the patients no substitution of blood products was documented. In most of the patients (20.4%) cytopenia was attributed to either heparin-induced thrombocytopenia (HIT) or hemato-oncologic (20.4%) diseases, followed by drug association in 18.5%. In 70.8% of the study patients PPIs were administered but the indication for PPI administration remained unclear in 20.4%. CONCLUSION: The results encourage accurate assessment of blood dyscrasias and appropriate documentation as well as indication check for PPI treatment in geriatric inpatients.

Prescription errors in geriatric patients can be avoided by means of a computerized physician order entry (CPOE).

BACKGROUND: The implementation of a computerized physician order entry (CPOE) can help reduce prescription errors in clinical practice. OBJECTIVE: The aim of this study was to evaluate the effects of a CPOE for geriatric patients with the two most common conditions for drug-induced iatrogenic diseases, dysphagia and renal failure. SUBJECTS AND METHODS: A retrospective analysis of actual drug prescriptions versus CPOE recommendations in the geriatric department of the St. Marien Hospital in Cologne, Germany was carried out. Actual drug prescriptions were collected for 26 patients with dysphagia (15 female, 11 male, average age 82.3 ± 8.0 years) and 35 patients with renal failure (23 female, 12 male, average age 80.5 ± 6.7 years) which were compared with recommended prescriptions by means of a CPOE and discrepancies were statistically analyzed. RESULTS: Prescription errors for at least 1 drug were detected in 46 % of patients with renal failure and the administration of at least 1 drug with inadequate crushing was observed in 77 % of dysphagia patients. CONCLUSION: Prescription errors appear to be frequent to highly frequent in the medical routine even in a highly specialized geriatric setting. Inaccuracies might be reduced by the implementation of a CPOE and even more if coupled to a decision support system. Drug-drug or drug-disease interactions, which are particularly high risks in patients with multimorbidities, multidrug therapy, renal failure or malnutrition, might be kept under control through careful verification of medication indications, organ function status as well as drug administration and preparation in cases of tube feeding.

Association of anemia and hypoalbuminemia in German geriatric inpatients: Relationship to nutritional status and comprehensive geriatric assessment.

BACKGROUND: Anemia and hypoalbuminemia (HA) are acknowledged independent risk factors for morbidity and mortality in geriatric patients and are associated with nutritional status and frailty. Data exist regarding the association between albumin and frailty, anemia and frailty as well as frailty and nutritional status; however, there is a lack of information on the association between HA, anemia and nutritional status in older people. PATIENTS AND METHODS: This study retrospectively analyzed 626 patients admitted to a German geriatrics department (average age 81.1 years, 68.2% female and 31.8% male) for anemia and HA. Data from the comprehensive geriatric assessment (CGA) and from the mini-nutritional assessment (MNA) were available in all patients. RESULTS: Patients with anemia suffered significantly more often from HA (p<0.001) than patients without anemia, with an odds ratio (OR) of 1.99 (95% confidence interval CI: 1.2-3.2) and of 5.41 (CI 95%: 2.3-12.6) in patients at risk for malnutrition and in malnourished patients, respectively. A moderately significant association was seen between hemoglobin (Hb) and albumin values (Pearson's correlation r=0.330; p<0.001) as well as between albumin values and the Barthel index (Spearman's correlation r=0.210; p<0.001). CONCLUSION: Anemia appears to be a risk factor for HA in inpatients with malnutrition and the observed association between albumin and Hb warrants further research. Geriatric inpatients with anemia should be evaluated in terms of the presence of malnutrition risk and HA.

[Serum hepcidin levels in geriatric patients with iron deficiency anemia or anemia of chronic diseases]. / Serumhepcidin bei Eisenmangelanämie und Anämie chronischer Erkrankungen im geriatrischen Kollektiv.

BACKGROUND: Iron deficiency anemia (IDA) and anemia of chronic diseases (ACD) are common in the geriatric population. However, differentiation between IDA and ACD is still problematic. Hepcidin is a key regulator of iron homeostasis: downregulation in the presence of iron deficiency allows enteral iron resorption, while upregulation in case of chronic inflammation blocks it. We aimed at studying whether serum hepcidin levels might serve as diagnostic parameter to differentiate between IDA and ACD among elderly. PATIENTS AND METHODS: A total of 37 patients (age 69-97 years) were divided into 4 groups: group I (IDA), group II (ACD), group III (controls), and group IV (IDA/ACD). Serum hepcidin levels were analyzed using a commercially available ELISA kit (DRG Instruments, Marburg, Germany). Differences in hepcidin levels were tested with nonparametric methods. RESULTS: We could show a strong positive correlation between serum hepcidin and ferritin (Spearman rho 0.747) and a statistic significant difference of hepcidin levels among all groups (p = 0.034). Hepcidin levels between ACD and controls differed significantly (p = 0.003). CONCLUSION: Despite the small number of patients included in this study, which reduces the strength of the study's evidence, results conform with the current literature: it can be assumed that hepcidin will be used as a diagnostic parameter to differentiate between IDA and ACD in the future. However, more studies with larger patient groups are urgently needed to answer this question.

[Anemia in the elderly]. / Anämie im Alter.

Anemia is not physiologically associated with increasing age but a symptom of an underlying disease. The individual patient's wish, results of geriatric assessment, and therapeutic options regarding life expectancy and quality of life must be taken into consideration when determining the diagnostic steps to be taken. Prevalence of anemia is high, reaching up to 40% among geriatric inpatients. There are various reasons for anemia, but the three most frequent forms of anemia in the elderly are iron deficient anemia (IDA), anemia of chronic diseases (ACD), and unexplained anemia (UA). This article will, therefore, be limited to these forms. Until now no guidelines have been developed concerning diagnostic and therapeutic steps for anemia in the elderly. For basic diagnostics, the analysis of hematologic parameters such as hemoglobin, ferritin, and the saturation of transferrin are recommended. Therapeutic options have to be chosen according to the underlying disease.

[Anemia in the elderly. Urgent need for guidelines]. / Anämie im Alter. Dringlicher Bedarf an einer Leitlinie.

The prevalence of anemia in the elderly is high and can reach among independent community-dwelling persons > 20% and among hospitalized geriatric patients up to 40%. Anemia in the elderly has numerous causes rather than being clearly age related. Although it is widely acknowledged that anemia influences morbidity and mortality in geriatric patients in a negative manner, guidelines concerning diagnostics and therapeutic steps do not exist in Germany. We present a work-up of guidelines of German (AWMF) and international (G-I-N, NGC) specialists' societies dealing with the subject "anemia." Regarding the demographic changes with a growing population of geriatric patients with anemia, the development of a national (German) guideline for an ethically acceptable and cost-effective management of anemia in the elderly is necessary.

[Anemia and iron deficiency in the elderly. Prevalence, diagnostics and new therapeutic options]. / Anämie und Eisenmangel in der Geriatrie. Prävalenz, Diagnostik und neue Therapieoptionen.

The prevalence of anemia in geriatric patients is high. With some variation in different patient cohorts, prevalence of anemia can reach 40%. Anemia is not an age-related disease on its own, but is a symptom with multifactorial genesis and high risk potential. It directly influences mortality, morbidity, and the rate of hospitalization, particularly in older patients suffering from chronic heart failure or chronic kidney disease. The high prevalence of anemia in chronic kidney disease is explained by a combination of erythropoietin and iron deficiency. This review summarizes the recommendations of the iron symposium at the 2010 German Geriatric Society Meeting in Potsdam, Germany. It intends to provide current information on prevalence, diagnostic work-up, and therapeutic options for anemia in the rapidly growing group of elderly patients.

Growth-stimulating influence of human chorionic gonadotropin (hCG) on Plasmodium falciparum in vitro.

In this study, it is reported that human Chorionic Gonadotropin (hCG), being one of the most important hormones of pregnancy, has a growth-stimulating effect on the asexual stages of Plasmodium falciparum in vitro. On the one hand, it is shown that the effect of the hormone is dose-related: The highest growth-rates of Plasmodium falciparum in vitro are achieved, when doses of 8.32 i.u./ml (= 50 i.u. hCG/6 ml) and 16.67 I.U./ml (= 100 i.u. hCG/6 ml) are added to the culture medium. These doses correspond to the physiological peak amounts of hCG between the 9th and 16th week of pregnancy, when parasitaemia also reaches its highest rate. On the other hand, it is shown, that any growth-stimulating effect disappears after inactivation of the hormone by heating at 120 degrees C for 20 minutes. These data support the hypothesis, that hCG does not only possess immunosuppressive properties acting on the response of T-lymphocytes, but also increases the growth of Plasmodium falciparum in vitro. The combination of both effects may explain why malaria still remains one of the most serious complications of pregnancy.

Congenital dyserythropoietic anemia type III associated with congenital atrioseptal defect has led to severe cardiac problems in a 32-year-old patient.

We report the case of a 32-year-old woman who was admitted at hospital because of ortho-dyspnea, arrhythmia, and paleness. Clinical examination showed continuous arrhythmia, systolic heart murmur, enlargement of spleen and liver, and pathologic hematological parameters, thus indicating an intravasal hemolysis (elevated HBDH, bilirubin, and reticulocytes; reduced hemoglobin and haptoglobin levels), and bone-marrow-smears showed a typical cytomorphology of CDA III. The patient's diagnosis was heart failure caused by mitral valve insufficiency due to congenital atrioseptal defect associated with congenital dyserythropoietic anemia type III (CDA III).

[Multilocular Castleman's Disease of the mixed type. An rare differential diagnosis in lymphadenopathy with weakness, weight loss and night-sweats]. / Multilokulärer Morbus Castleman vom gemischten Typ - Eine seltene Differenzialdiagnose bei Lymphadenopathie mit Schwäche, Gewichtsverlust und Nachtschweiss

HISTORY AND CLINICAL FINDINGS: A 36 years old nurse had been suffering from prolonged weakness, weight-loss of 6 kg, night-sweat and painful swelling of neck lymph nodes for one year. On admission she was in a reduced physical condition. Nuchal, cervical and inguinal lymphnodes were enlarged bilaterally. INVESTIGATIONS: Computed tomography showed enlarged lymph nodes in the neck and inguinally. Histology of the biopsies revealed the diagnosis of the mixed variant of Castleman's Disease. TREATMENT AND COURSE: A steroid treatment was initiated, administering 100 mg prednisone for 2 weeks, 75 mg for another 2 weeks and 50 mg for a month. The dose was then gradually reduced by steps of 10 mg. After 3 months the patient's physical state and lymph nodes were normalized. So treatment was terminated and the nurse was able to take up work again. CONCLUSION: If confronted with general lymphadenopathy associated with B-symptoms even without fever a Castleman's Disease should be taken into consideration. The prognosis of the multivariant form is uncertain. Transformation to malignant lymphoma is frequent.